Please fill out the following non-binding form to receive information from TRIARQ Health about the BPCI-Advanced Program.

You're not signing up for the program.

You're not comitting to the program.

We just need your signature in order for TRIARQ to get the necessary data from CMS to give you an accurate idea of the benefits you may see from joining the BPCI-Advanced program as part of the TRIARQ Health Alliance.

Non-Binding Statement-of-InterestUNTIL EXECUTION AND DELIVERY OF DEFINITIVE AGREEMENTS, ALL PARTIES SHALL HAVE THE ABSOLUTE RIGHT TO TERMINATE ALL NEGOTIATIONS FOR ANY REASON WITHOUT LIABILITY THEREFOR THIS IS NOT AN OFFERING. AN OFFERING WILL ONLY BE MADE THROUGH AN APPROPRIATE AGREEMENT AND ADDITIONAL MATERIALS IN COMPLIANCE WITH APPLICABLE SECURITIES LAWS. THIS DOCUMENT IS NOT INTENDED TO BE A BINDING AGREEMENT WITH RESPECT TO THE SUBJECT MATTER HEREOF.

This Statement of Interest is made as of the date signed below by the undersigned physician (“Physician”) to TRIARQ Health, LLC. (“TRIARQ”).

The Alliance is a Clinically Integrated Network of orthopedic surgeons and post-acute care participating providers formed to contract with third party payers and employers to provide value-based care including bundled pricing for orthopedic surgery and other services, incorporating principles of clinical and financial integration. (the “Alliance”). The Alliance is a Medicare Convener participating in the BPCI-Advanced program.

Physician is interested in learning more about participation in the Alliance, and is willing to indicate his or her interest with CMS to receive and review his or her data provided by CMS during the CMS evaluation period, understanding it is a non-binding obligation to evaluate the CMS Advanced Bundled Payment Initiative for joint replacements or back/spine procedures.

ACCORDINGLY, PHYSICIAN STATES AS FOLLOWS:

I understand that this is an indication of interest only at this point. It is a non-binding commitment on my part, and does not create any obligation on the part of TRIARQ, but will be used by TRIARQ to enter into discussions with CMS and/or Commercial Payers to determine participation in the BPCI Advanced Bundle Payment Program or Commercial Bundled Payment Programs.

Any binding commitment by me will be made only after I receive a participation agreement or offering memorandum, and TRIARQ and I sign all necessary legal documents and other materials, which TRIARQ will present for my final approval.